Otolaryngology Disorders - Oropharynx PDF

Otolaryngology Disorders PAMA 5619 – Clinical Medicine I Semester II Spring Tong Pineda, MD Then the Lord God formed the man from the dust on the ground. He breathed the breath of life into the man’s nostrils, and the man became a living person....

Otolaryngology Disorders PAMA 5619 – Clinical Medicine I Semester II Spring Tong Pineda, MD Then the Lord God formed the man from the dust on the ground. He breathed the breath of life into the man’s nostrils, and the man became a living person. Genesis 2:7 NLT Current Medical Diagnosis & Treatment 2025 by Maxine A. Papadakis, Stephen J. McPhee, Michael W. Rabow, Kenneth R. McQuaid Harrison's Principles of Internal Medicine, 21e by Joseph Loscalzo, Anthony Fauci, Dennis Kasper, Stephen Hauser, Dan Longo, J. Larry Jameson Textbooks for this module Head, Ears, Nose, Oral, Throat Module Specific Objectives 1. Identify common injuries involving the head and face. 2. Recognize and differentiate between pathophysiologic causes of conductive and sensorineural hearing loss. (B2.02c) 3. Recognize and differentiate between pathophysiologic causes of peripheral and central vertigo. (B2.02c) 4. Compare and contrast common etiologies of pharyngitis and tonsillitis and describe the clinical presentation. 5. Describe the Centor criteria and how it is used in the management of GABHS pharyngitis. 6. Identify the risk factors associated with the development of oral cancer. Head, Ears, Nose, Oral, Throat Module Specific Objectives 7. Identify the common conditions affecting the teeth and gum. 8. Distinguish between anterior epistaxis and posterior epistaxis and identify the appropriate management. Leukoplakia, Erythroplakia, Lichen Planus, & Oropharyngeal Cancer Leukoplakia – A whitish plaque-like lesion that cannot be removed by rubbing the mucosal surface. Small to several centimeters in diameter Histologically – hyperkeratosis in response to chronic irritation (eg. dentures, tobacco, lichen planus) 2-6% - dysplasia or early invasive squamous cell carcinoma Squamous cell carcinoma accounts for 90% of oral cancer Need to distinguish from erythtroplakia because 90% of erythroplakia – dysplasia or carcinoma Alcohol and tobacco – major epidemiologic risk factors Leukoplakia with moderate dysplasia on the lateral border of the tongue. (Used, with permission, from Ellen Eisenberg, DMD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.) Citation: 8-16 Leukoplakia, Erythroplakia, Lichen Planus, & Oropharyngeal Cancer, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476892 Accessed: January 23, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Erythroplakia – Similar to leukoplakia except that it has a definite erythematous component Any area of erythroplakia or enlarging leukoplakia – incisional biopsy Ulcerative lesions are worrisome Systematic oral examination is warranted Specialty referral early for diagnosis and treatment Current or former tobacco use or moderate alcohol drinking history - higher risk No approved therapies to date. Erythroplakia Oral Lichen Planus – Most commonly presents as lacy leukoplakia but may be erosive Common (0.5-2% of the population Chronic inflammatory autoimmune disease – mimics other diseases Definite diagnosis – incisional or excisional biopsy Therapy – manage pain and discomfort Daily topical corticosteroid 1% => SCC Lichen Planus Hairy Leukoplakia – Occurs on the lateral border of the tongue and is a common early finding in HIV infection. May occur following solid organ transplantation and associated with EBV infection and long-term systemic corticosteroid use Waxes and wanes Acyclovir, valacyclovir, and famciclovir Does not predispose to malignancy Oral hairy leukoplakia on the side of the tongue in AIDS. (Reproduced with permission from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.) Citation: 8-16 Leukoplakia, Erythroplakia, Lichen Planus, & Oropharyngeal Cancer, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476892 Accessed: January 23, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Oral cavity squamous cell carcinoma Hard to distinguish from other oral lesions – early detection is key. Raised, firm, ulcerative lesions, painful on palpation. If less that 3 mm in depth – low propensity to metastasize. Cure rates are high if resected before it is 2 cm in diameter. Radiation from metastatic disease or tumors with adverse features. Chemotherapy – lymph node extension Large tumors – resection, removal of lymph nodes from the neck, and external beam radiation. Reconstruction if required. Squamous cell carcinoma of the palate. (Used, with permission, from Frank Miller, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.) Citation: 8-16 Leukoplakia, Erythroplakia, Lichen Planus, & Oropharyngeal Cancer, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476892 Accessed: January 24, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Oropharyngeal squamous cell carcinoma Generally presents later than oral cavity squamous cell carcinoma. Lesions tend to be larger and often buried within the lymphoid tissue of the palatine or lingual tonsils. Unilateral odynophagia and weight loss, ipsilateral cervical lymphadenopathy. Tobacco, alcohol, and HPV. Chemotherapy and radiation. Oral Candidiasis (trush) Fluctuating throat or mouth discomfort – painful Creamy-white-curd-like patches overlying erythematous mucosa. These white areas are easily rubbed off (eg, tongue depressor) – unlike luekoplakia or lichen planus Risk factors: 1. Dentures 2. Debilitated state with poor oral hygiene 3. Diabetes mellitus 4. Anemia 5. Chemotherapy or local irradiation 6. Corticosteroid use (oral or systemic) 7. Broad spectrum antibiotics Angular cheilitis (nutritional deficiency) Oral mucosal candidiasis. (Sol Silverman, Jr., DDS/Centers for Disease Control and Prevention.) Citation: 6-21 Mucocutaneous Candidiasis, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288473660 Accessed: January 24, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Oral Candidiasis (trush) Diagnosis – clinical Wet prep with potassium hydroxide will reveal spores and nonseptate mycelia. Biopsy shows intraepithelial pseudomycelia of Candida Albicans Candidiasis is often the first manifestation of HIV infection, and HIV testing should be considered in patients with no known predisposing cause for Candida growth. Patients with HIV – oral mucosa exam every 6 months Treatment – Fluconazole (100 mg orally x 7 days) Ketoconazole (200-400 mg orally with breakfast (requires gastric acid for absorption) Nystatin mouth rinses (500,00 units) held in mouth before swallowing TID. Nystatin powder applied to dentures. Glossitis, Glossodonyia, & Burning Mouth Syndrome Glossitis – inflammation of the tongue with loss of filiform papillae. Red, smooth surfaced tongue, not painful. Secondary to nutritional deficiencies (eg, niacin, riboflavin, iron, or vitamin E), drug reactions, dehydration, irritants, or foods and liquids, autoimmune reactions or psoriasis. Glossodynia – burning and pain of the tongue, which may occur with or without glossitis. When no clinical findings – “burning mouth syndrome” Glossodynia with glossitis – Associated with DM, medications (eg, diuretics), tobacco, xerostomia, candidiasis, and glossitis causes. No identifiable associated risk factors. Most common in postmenopausal women. Treatment – Clonazepam 0.25mg to 0.5 mg on the tongue Q8-12h Both glossodynia and burning mouth syndrome are benign – reassurance Unilateral symptoms and involve other regions – neuropathology – MRI Glossitis Intraoral Ulcerative Lesions Necrotizing Ulcerative Gingivitis (trench mouth, Vincent angina) Painful, acute gingival inflammation and necrosis, often with bleeding, halitosis, fever, and cervical lymphadenopathy. Often caused by an infection with both spirochetes and fusiform bacilli – common in young adults under stress (Exams!!) Underlying systemic diseases may also predispose ulcers. Warm half-strength peroxide rinses and oral penicillin (250 mg TID) x 10 days. Dental gingival curettage. Necrotizing Ulcerative Gingivitis (trench mouth, Vincent angina) Apthous Ulcer (canker sore, ulcerative stomatitis) Very common and easy to recognize. Single or multiple painful, small round ulcerations with yellow-gray fibrinoid centers surrounded by red halos. Buccal and labial mucosa and not attached to gingiva or palate) Minor < 1 cm in diameter. Heals 10-14 days. Major >1 cm. Disabling pain Stressssssss Treatment is challenging – no single systemic treatment has been proven effective. Avoid local irritants Apthous Ulcer (canker sore, ulcerative stomatitis) Treatment – Topical corticosteroids (triamcinolone actetonide, 0.1%, or fluocinide ointment, 0.05%) in an adhesive base (Orabase Plain) – symptomatic relief 1 week tapering course of prednisone (40-60 mg/day) has been successful Recurrent – cimetidine maintenance therapy Thalidomide for HIV patients When large or persistent or diagnosis not clear – incisional biopsy Aphthous Ulcer Herpes Stomatitis Herpes gingivostomatitis is common, mild, and short- lived. Initial burning, followed by typical small vesicles that rupture and form scabs. Commonly found on the attached gingiva, mucocutaneous junction of the lip, tongue, buccal mucosa, and soft palate. In most adults – no intervention. In immunocompromised persons – HSV infections may be severe. Treat with Acyclovir (200-800 mg orally 5xday x 7-10 days, or valacylcovir (1000 mg orally twice daily for 7-10 days) Effective if started within 24-48 hours of onset of initial symptoms (pain, itching, burning) DDX –aphthous stomatitis, erythema multiforme, syphilitic chancre, and carcinoma Herpes Stomatitis Pharyngitis & Tonsillitis Centor criteria for streptococcal pharyngitis: exudate or swelling tonsils, anterior cervical adenopathy, fever, lack of cough Pharyngitis and tonsillitis account for over 10% of all office visits to primary care clinicians and 50% of antibiotic use. Main concern – group A beta-hemolytic streptococcal (GABHS) infection – may lead to subsequent complications, such as rheumatic fever (rash, artharlagia, myocarditis), glomerulonephritis, and posterior pharyngeal abscess. Second – public health policy – reducing cost (both in dollars and development of antibiotic- resistant S pneumoniae) Pharyngitis & Tonsillitis Clinical findings for GABHS – 1. Fever >38° C 2. Tender anterior cervical lymphadenopathy 3. Lack of cough 4. Pharyngotonsillar exudate Centor criteria – all 4 strongly suggests GABHS 2 or 3 of the four – intermediate likelihood of GABHS When only 1 – unlikely Sore throat may be severe, with odynophagia, tender adenopathy, and a scarlatiniform rash. Pharyngitis & Tonsillitis Clinical findings for GABHS – Elevated white count and left shift are possible Hoarseness, cough, and coryza are not suggestive of this disease. It is also rare < 3 years old Marked lymphadenopathy and a shaggy, white- purple tonsillar exudate, often extending to the nasopharynx – Infectious mononucleosis – young adult. 1/3 of patients with IM have secondary streptococcal tonsilitis, requiring treatment Pharyngitis & Tonsillitis Most common pathogens other than GABHS in the ddx of sore throat are viruses. Rhinorrhea and a lack of exudate would suggest a virus – but hard to confidently distinguish on clinical grounds alone. Laboratory findings – A single-swab culture is 90-95% sensitive and the rapid antigen detection testing (RADT) is 90- 99% sensitive for GABHS. RADT results - ~15 minutes. Routine throat culture in refractory cases may also be helpful – antibiotic selection Pharyngitis & Tonsillitis Treatment – 0-1 Centor criteria – very low rish of GABHS – no throat culture or RADT – no antibiotics 2-3 Centor criteria – need throat cultures or RADT – if positive – antibiotics all 4 Centor criteria – likely GABHS – can receive empiric therapy without throat cuture or RADT Oral antibiotics – preferred first line – 1. Penicillin V potassium (250 mg orally TID or 500 mg BID x 10 days) 2. Cefuroxime axetil (250 mg orally BID 5-10 days 3. Erythromycin – for penicillin allergy 4. Cefpodoxime and cefuroxime 5. Azithromycin (500 mg QD x 3 days) 6. Single IM injection of benzathine penicillin or procaine penicillin, 1.2 million units Second course is reasonable. Pharyngitis & Tonsillitis Treatment – Watch out of for antibiotic resistance in your area. Ancillary treatment – 1. Analgesics and anti-inflammatory agents (eg, aspirin, acetaminophen, and corticosteroids) 2. Salt water gargling 3. Anesthetic gargles and lozenges 4. If odynophagia is severe – hospitalization for hydration and antibiotics Patients who have had rheumatic fever should be treated with penicillin G, 500 mg orally QD, or erythromycin 250 mg QD orally for at least 5 Marked exudative pharyngitis and tonsillitis due to group A beta-hemolytic streptococci. (Used, with permission, from Lawrence B. Stack, MD, in Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine, 5th ed. McGraw Hill, 2021.) Citation: 8-20 Pharyngitis & Tonsillitis, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476937 Accessed: January 24, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Peritonsillar Abscess & Cellulitis Infection that penetrates the tonsillar capsule and involves surrounding tissues. Presents as severe sore throat, odynophagia, trismus, medial deviation of the soft palate, and peritonsillar fold, and an abnormal muffled “hot potato” voice. Confirm abscess with aspiration – 19-gauge or 21-gauge needle should be passed medial to the molar and no deeper than 1 cm. to avoid internal carotid artery. Treatment – Parenteral amoxivilin (1g), amoxixillin-sulbactam (3g), or clindamycin (600-900 mg) Less severe – amoxicillin 500 mg TID orally; amoxicillin- clavulanate 875 mg BID; clindamycin 300 mg QID x 7-10 days. Surgery – needle aspiration, I&D, tonsillectomy – controversial – complications Recurrent or atypical in adults – malignancy? Peritonsillar infection. A: Acute peritonsillar abscess showing medial displacement of the uvula, palatine tonsil, and anterior pillar. B: Peritonsillar abscess seen on CT with a ring-enhancing lesion with a hypodense core. C: Peritonsillar phlegmon showing marked erythema of the tonsillar pillars but without swelling or fluctuance. (Photo contributor: Lawrence B. Stack, MD.) (Used with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ, eds. The Atlas of Emergency Medicine, 5e. New York, NY: McGraw Hill; 2021.) Citation: 8-21 Peritonsillar Abscess & Cellulitis, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476958 Accessed: January 24, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Peritonsillar infection. A: Acute peritonsillar abscess showing medial displacement of the uvula, palatine tonsil, and anterior pillar. B: Peritonsillar abscess seen on CT with a ring-enhancing lesion with a hypodense core. C: Peritonsillar phlegmon showing marked erythema of the tonsillar pillars but without swelling or fluctuance. (Photo contributor: Lawrence B. Stack, MD.) (Used with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ, eds. The Atlas of Emergency Medicine, 5e. New York, NY: McGraw Hill; 2021.) Citation: 8-21 Peritonsillar Abscess & Cellulitis, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476958 Accessed: January 24, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Peritonsillar infection. A: Acute peritonsillar abscess showing medial displacement of the uvula, palatine tonsil, and anterior pillar. B: Peritonsillar abscess seen on CT with a ring-enhancing lesion with a hypodense core. C: Peritonsillar phlegmon showing marked erythema of the tonsillar pillars but without swelling or fluctuance. (Photo contributor: Lawrence B. Stack, MD.) (Used with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ, eds. The Atlas of Emergency Medicine, 5e. New York, NY: McGraw Hill; 2021.) Citation: 8-21 Peritonsillar Abscess & Cellulitis, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476958 Accessed: January 24, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved When needle aspiration is used to manage peritonsillar abscess, aspiration should be attempted at each of these three anatomic locations. (Reproduced with permission from Saunders CE, Ho MT. Current Emergency Diagnosis & Treatment, 4th ed. Appleton & Lange: The McGraw Hill LLC Companies, Inc; 1992.) Citation: 8-21 Peritonsillar Abscess & Cellulitis, Papadakis MA, Rabow MW, McQuaid KR, Gandhi M. Current Medical Diagnosis & Treatment 2025; 2025. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=3495&sectionid=288476958 Accessed: January 24, 2025 Copyright © 2025 McGraw-Hill Education. All rights reserved Deep Neck Infections Deep neck abscesses most commonly originate from odontogenic infections. Other causes – -suppurative lymphadenitis (smoker/alcohol/middle age – r/o malignancy) - direct spread of pharyngeal infection - penetrating trauma - pharyngoesophageal FB - cervical osteomyelitis - intravenous injection of the internal jugular vein – substance abuse Ludwig angina – most common – cellulitis of the sublingual and submaxillary spaces – infection from mandibular dentition – Emergency - may cause rapid airway compromise – surgical airway Recurrent – underlying congenital lesion – branchial cleft cyst Deep Neck Infections Clinical findings – These are emergencies! Occlusion of airway Marked acute neck pain and swelling Fever is common but not always present Edema and erythema of the upper neck under the chin and often of the floor of the mouth Tongue maybe displaced upward and backward Coalescence of pus is present in the floor of the mouth May spread to mediastinum or cause sepsis CT – define extent of abscess Lemierre syndrome – rare, thrombophlebitis of internal jugular vein Deep Neck Infections Treatment – 1. Secure airway – intubation or tracheotomy 2. Intravenous antibiotics 3. Incision and drainage 4. Culture and sensitivity 5. Dental consultation 6. External drainage via bilateral submenta incisions Penicillin plus metronidazole, ampicillin- sulbactam, clindamycin, or selective cephalosphorins Lemierre syndrome – Fusobacterium necrophorum Ludwig’s Angina Snoring Noise produced on inspiration due to aerodigestive tract blockage during sleep. Narrowing of the upper aerodigestive tract due to changes in position, muscle tone, and soft tissue hypertrophy or laxity. Simple snoring  cessation of airflow  obstructive sleep apnea (OSA)with long periods  life-threatening physiologic sequelae. Snoring is associated with OSA but may not alone disrupt sleep quality. 5-10% of Americans. Clinically relevant snoring may occur in as many as 59%. Snoring is a social problem. All patients who Snoring Symptoms – 1. Excessive daytime somnolence 2. Daytime headaches 3. Weight gain Present in as many as 30% of patients without demonstrable apnea or hypopnea on formal testing. Clinical examination – Inspect nasal cavity, nasopharynx, oropharynx, and larynx to exclude other cause of dynamic airway obstruction. In isolated snoring – palate and uvula appear enlarged and elongated Diagnostic testing – Snoring Treatment – Diet modification and physical exercise Weight loss and avoidance of alcohol and hypnotic medications Position change during sleep – golf/tennis ball on the back CPAP – continuous positive airway pressure – adherence is suboptimal – 75% abandon after 1 year Oral mandibular device Pharmacologic therapies - ? Surgical – improve airflow – Uvulopalatopharyngoplasty, nasal septoplasty, tracheostomy, hypoglossal nerve stimulation - worth Acute Inflammatory Salivary Gland Disorders Sialadenitis – Acute bacterial sialadenitis commonly affects the parotid or submandibular gland. Presents with acute swelling of the gland, increased pain and swelling with meals, and tenderness and erythema of the duct opening. Pus can be massaged from the duct. Often occurs in the setting of dehydration or in association with chronic illness – underlying Sjögren syndrome or chronic periodontitis. Acute Inflammatory Salivary Gland Disorders Sialadenitis – Staphylococcus Aureus – most common causative agent Treatment – Intravenous nafcillin (1 gm intravenously Q4-6h, then switch to oral Hydration, warm compresses, lemon drops, massage of the gland Less severe cases – oral antibiotics for 10 days Resolution may tale 2-3 weeks Suppurative sialadenitis – severe – may require I&D Sialadenitis - submandibular Sialadenitis – parotid gland Acute Inflammatory Salivary Gland Disorders Sialolithiasis – Calculus formation is more common in the Wharton duct (draining the submandibular glands) than in the Stensen duct (draining the parotid glands). Clinically – postprandial pain and local swelling, often with a history of recurrent acute sialadenitis. Stones in the Wharton duct are large and radiopaque. Stones in the Stensen duct are usually radiolucent and smaller. May be able to palpate and removed intraorally by dilating or incising the distal duct. Sialoendoscopy > extracorporeal shock-wave lithotripsy Sialolithiasis Sialolithiasis Chronic Inflammatory & Infiltrative Disorders of the Salivary Glands Sjögren syndrome and sarcoidosis – affect the salivary gland Metabolic disorders – alcohol use disorder, diabetes mellitus, vitamin deficiencies Medications – thioureas, iodine, phenothiazines Salivary Gland Tumors General rule of thumb – smaller the size of the salivary gland with a present mass, the more likely the possibility of malignancy. Approximately 80% of slavery gland tumors occur in the parotid gland. In adults, 80% of these are benign 50-60% of primary submandibular tumors are benign. Tumors of the minor salivary gland are most likely malignant – adenoid cystic carcinoma Most are asymptomatic. Facial nerve involvement + pain = malignant MRI, CT, and US Hoarseness & Stridor The primary symptoms of laryngeal disease is hoarseness and stridor. Hoarseness is caused by an abnormal vibration of the vocal folds. The voice is breathy when too much air passes incompletely apposed vocal folds – unilateral vocal fold paralysis or vocal fold mass. The voice is harsh when the vocal folds are stiff and vibrate irregularly – laryngitis or malignancy. The voice is rough, low-pitched when vocal Hoarseness & Stridor Stridor is high-pitched, typically inspiratory sound - as a result of turbulent airflow from a narrowed airway Airway narrowing or at above the vocal folds – inspiratory Airway narrowing below the vocal folds – expiratory or biphasic stridor Timing and rapidity – clinically important  seriousness of the condition – rapid onset  emergent All patients with hoarseness that persists beyond 2 weeks should be evaluated by Common Laryngeal Disorders Laryngopharyngeal Reflux Hoarseness, throat irritation, heartburn, foreign body sensation, and chronic cough Symptoms typically occur when upright – many patients – do not experience classic heartburn Gastroesophageal reflux into the larynx is considered a cause of chronic hoarseness when other causes have been excluded GERD – throat clearing, throat discomfort, chronic cough, sensation of postnasal drip, esophageal spasm, asthma Laryngoscopy Common Laryngeal Disorders Laryngopharyngeal Reflux Hoarseness, throat irritation, heartburn, foreign body sensation, and chronic cough Symptoms typically occur when upright – many patients – do not experience classic heartburn Gastroesophageal reflux into the larynx is considered a cause of chronic hoarseness when other causes have been excluded GERD – throat clearing, throat discomfort, chronic cough, sensation of postnasal drip, esophageal spasm, asthma Laryngoscopy Common Laryngeal Disorders Epiglottitis Epiglottitis (supraglottitis) should be suspected with a rapidly developing sore throat or when odynophagia is out of proportion to apparently minimal oropharyngeal findings on examination. Common with diabetics Viral or bacterial Layngoscopy – swollen, erythematous epiglottitis Treatment – hospitalization for IV antibiotics Ceftizoxime, 1-2 g intravenously Q8-12h or Cefuroxime, 750-1500 mg IV Q8h and Dexamethasone, 4-10 mg bolus, then 4 mg IV Q6h Intubate – dyspnea, rapid pace of sore throat, endolaryngeal abscess noted on CT Epiglottitis – “thumb sign” on lateral plain radiograph Masses of the Vocal fold nodules – smooth Larynx paired lesions that form at the junction of the anterior one-third Traumatic and posterior two-thirds of the vocal folds. Lesions of the Vocal Folds Common cause of hoarseness resulting from vocal abuse In adults – “singer’s nodules”; in children – “screamer’s nodules” Treatment – modification of voice habits and referral to speech therapist Recalcitrant – surgical removal Masses of the Vocal fold polyps – unilateral Larynx masses that from within the superficial lamina propia of the Traumatic vocal fold Lesions of the Related to vocal trauma – vocal Vocal Folds fold hemorrhage Small, sessile polyps may resolve with conservative measures – voice rest and corticosteroids Larger – irreversible – surgical removal Vocal fold polyp and removal Masses of the Vocal fold cyst – also considered Larynx traumatic lesions of the vocal folds True cysts with an epithelial lining Traumatic or pseudocysts Lesions of the Vocal Folds Typically form from mucus- secreting glands on the inferior aspect of the vocal folds May fluctuate in size – variable degree of hoarseness Rarely resolve completely scarringdysphonia Masses of the Polypoid corditis – loss of elastin Larynx fibers and loosening of intracellular junctions within Traumatic lamina propia swelling of gelatinous matrix Reinke edema Lesions of the Vocal Folds Smoking, vocal abuse, chemical industrial irritants, and hypothyroidism Masses of the Contact ulcers or granulomas – Larynx both form on the vocal processes of the arytenoid cartilages Traumatic Cause ? Lesions of the Common following intubation and Vocal Folds generally resolve quickly Chronic – GERD Treatment – multimodal Fluticasone 440mcg twice daily, omeprazole 40 mg orally BID Voice therapy Surgical removal Masses of the Leukoplakia of the vocal folds is Larynx commonly associated with hoarseness in smokers. Laryngeal Direct laryngoscopy with biopsy is Leukoplakia adviced Histology – mild, moderate, or severe dysplasia May find invasive squamous cell carcinoma 35-60% of severe  SCC Cessation of smoking; PPI therapy, close follow up  Squamous cell carcinoma of the Masses of the larynx, the most common Larynx malignancy of the larynx, occurs almost exclusively in patients with a history of significant tobacco Squamous Cell abuse. Carcinoma of HPV is another association the Larynx Very treatable and early detection is the key to maximizing posttreatment coice, swallowing, and breathing function Clinical findings – change in voice, throat or ear pain, hemoptysis, dysphagia, weight loss, airway compromise New and persistent (greater than 2 weeks’ duration voice changes and hoarseness Persistent throat pain; stridor Masses of the CT and MRI – tumor extenrt Larynx Biopsy, esophagoscopy, bronchoscopy Tumor staging Squamous Cell Carcinoma of Treatment – 4 goals = cure + preserve the Larynx swallowing + preserve voice + avoidance of permanent tracheostoma Radiation – early stages – 80-95% cure rate Total laryngectomy – for advanced resectable ntumors with extralaryngeal spread Long term follow up Vocal Fold Vocal fold paralysis can result Paralysis from a lesion or damage to either the vagus nerve or recurrent laryngeal nerve. Breathy dysphonia, effortful voicing,ration, and rarely airway compromise. Common cause of recurrent laryngeal nerve – thyroid surgery, other neck surgery, mediastinal or apical involvement by lung cancer Skull base tumors – vagus nerve Second most common cause - idiopathic Vocal Fold Vocal fold paralysis – unilateral Paralysis – occasionally temporary and may take a year to spontaneously resolve Surgical – persistent Vocal fold paralysis – bilateral – causes inspiratory stridor with deep inspiration Cricothyrotomy The 3 main approaches to secure &Tracheostomy an airway include – endotracheal intubation, cricothyrotomy, and tracheostomy Acute emergency where the airway above the trachea is blocked (trauma, mass, or bleeding) cricothyrotomy secures more rapidly than tracheotomy When secure cricothyrotomytracheotomy https://www.youtube.com/watch?v =MGVuKvcepP4&ab_channel=Med zcool https://www.youtube.com/watch?v =luhQWqF2EY4&ab_channel=Larr Cricothyrotomy &Tracheostomy Tracheotomy – 2 primary indications: airway obstruction at or above the level of the larynx and respiratory failure requiring prolonged mechanical ventilation As soon as it is apparent that the patient will require protracted ventilatory support, tracheotomy should be replaced with endotracheal tube Posttracheotomy care – humidified air and cleaned several times a day –suction and care of skin around Foreign Bodies Aspiration of foreign bodies occurs in the Trachea much less frequently in adults than children. and Bronchi Older adults and those who wear dentures appear to be at greater risk Heimlich maneuver – less deaths If Heimlich is not successful – cricothyrotomy may be necessary in acute setting. If no airway compromise, CXR – radioopaque foreign body Tracheal and bronchial FB – GA – flexible bronchoscopy Foreign Bodies Foreign bodies in the esophagus are in the typically non emergent – depends Esophagus on the type of FB – or airway is compromised Button battery ingestion is a surgical emergency Drooling? Cannot handle secretions? Laryngoscopy and or plain films CT or barium swallow Treatment depends on FB Esophagoscopy or rigid laryngoscopy Diseases Differential diagnosis – location in the Presenting as neck, age of the patient, and the presence of associated disease Neck Masses processes. Rapid growth and tenderness – inflammatory Firm, painless, and slowly enlarging masses are often neoplastic Young adults – mostly benign Lymphadenopathy – HIV lymphoma >40 – most common – cancer – primary or metastases FNA biopsy  Congenital Branchial Cleft Cysts – present as soft cystic mass along the anterior Lesions border of the sternocleidomastoid Presenting as muscle. Neck Masses Noticed when they swell or get infected Excise to prevent recurrent infection or carcinoma – include tracts First BCC – high in the neck, at times below the ear; fistula with floor of external auditory canal Second BCC – more common; may communicate with tonsillar fossa Third BCC – may communicate with the piriform sinus - rare Thyroglossal Thyroglossal Duct Cysts – Duct Cyst present as midline neck mass, often just below the hyoid bone May occur at any age – most common before age 20 Surgical excision – prevent recurrent infection and rare malignancy Requires the removal of the entire fistulous tract along the midline portion of the hyoid bone Thyroglossal Thyroglossal Duct Cysts – Duct Cyst present as midline neck mass, often just below the hyoid bone May occur at any age – most common before age 20 Surgical excision – prevent recurrent infection and rare malignancy Requires the removal of the entire fistulous tract along the midline portion of the hyoid bone Infectious & Reactive Cervical Inflammatory Lymphadenopathy – normal lymph Neck Masses nodes are usually less than 1 cm in length. Infections involving the pharynx, salivary glands, and scalp often cause tender enlargement of neck nodes. Common in HIV Treatment – underlying disease I&D – node that supporates Smoker/alcohol use/ previous cancer – enlarged node (>1.5 cm) with necrotic center and not associated with an obvious infection – FNA Tuberculous & Granulomatous neck masses Nontuberculous (TB) are uncommon in the US Mycobacterial lymphadenitis is on the rise Presents as single or matted nodes. FNA biopsy, smear acid fast bacilli, mycobacterium culture – PCA from FNA Nontuberculous – treatment depends on culture Lyme Disease Lyme disease is caused by spirochete Borrelia bugdorferi and transmitted by ticks of the Ixodes genus 75% patients have symptoms involving head and neck Facial paralysis, hearing loss, dyesthesias, dysgeusia, or other cranial neuropathies Headache, pain, and cerbical lymphadenopathy Cancer In older adults, 80% of firm, Metastases persistent, enlarging neck masses are metastatic in origin. Majority from squamous cell carcinoma of the upper aerodigestive tract, such as nasopharynx, tonsils, tongue base, and larynx Complete head and neck exam, imaging, FNA, CT, MRI, PET scan Lymphoma 10% of lymphomas present in head and neck Multiple rubbery nodes FNA/open biops